Well-Being and Coping Capacities of Adolescent Students with Hearing Loss in Mainstream Schools.

Objectives Coping strategies used by adolescents has an important role in preventing or decreasing their stresses and also increasing their well-beings. This study aimed at evaluating the coping capacity and well-being of adolescent students with hearing loss in mainstream schools and also the correlations between their coping strategies and positive characteristics of well-being (engagement, perseverance, optimism, connectedness and happiness (EPOCH). Materials & Methods In this correlational study, 122 adolescent students with hearing loss were randomly selected from mainstream schools. Data collection was done by EPOCH Measure of Adolescent Well-Being and the Ways of Coping Questionnaire (WAYS). The Spearman correlation coefficient was used for determining the correlations between variables. Results The mean scores of using different coping strategies varied from 1.36 in problem solving to 1.44 in seeking support. Among the positive characteristics of well-being, happiness had the lowest (11.04) and connectedness showed the highest score (12.33). The findings also showed a significant correlation between all coping strategies and EPOCH, however there was a strong positive correlation between total coping strategy score and perseverance (0.648) and happiness (0.629). Conclusion Based on the results, the score of happiness in students with hearing loss was the lowest among positive characteristics of well-being and also happiness showed a strong association with total scores in coping strategies. Accordingly, interventional studies are needed to examine whether training students with hearing loss to use coping strategies is effective in increasing their happiness and overall well-being.


Introduction
Adolescence is a period of significant changes in biological, psychological, socio-emotional and cognition development that can be associated with behavioral, social and health problems (1).
Through this period, people are more exposed to increased rates of stressful situations than their childhood. There are several strategies to deal with stress, which are called coping styles (2).
They have been categorized as problem-focused versus emotion-focused coping styles (3) as well as approach versus avoidance coping styles (4).
The most commonly used coping strategies by adolescents are seeking social support, problem solving, avoidance coping, palliative emotion regulation and anger-related emotion regulation (5). Stress is one of the factors that negatively affect individual's well-being. There are some evidences that increase in stressors is a potential threat to the well-being and healthy development of adolescents (6). Well-being refers to the healthy functioning (physiological, psychological and behavioral), positive social relationships and a safe social life (7). Seligman (8)  hearing loss as an acquired and also as a congenital disability (11). The acquired and unexpected disability, such as late onset hearing loss causes the individuals to experience more stresses, losses, grief and stigmas. However, they state that hearing loss as a chronic illness and disability (CID) limits the individuals to engage in daily life activities.
Several CID hearing loss cases can be degenerative, which means that the individual's performance can be declined overtime. Stress, adaptation, quality of life and especially psychological well-being are the great concerns for those with this condition.

Therefore, continuous adaptation and interventions
to facilitate coping seems very important.
Adolescents with hearing loss are often faced with the additional challenge of adapting to hearing world, where communication and also access to information is difficult (12). Those enrolled in mainstream schools (regular schools including students with disability) have the additional challenge with their hearing peers, many of whom may not share a language with them (12).
Brunnberg, Boström and Berglund (13) found more mental symptoms and school problems in adolescents with hearing impairment compared to their normal hearing classmates. Exposure to different stressors is typically associated with low levels of well-being (14).
Children with hearing loss may experience higher level of stress (15) and lots of problems regarding school and greater psychosocial difficulties, such as internalizing symptoms (16). Problems while using a hearing aid, amplitude and duration cues, communication and education problems impose Iran J Child Neurol. winter 2020 Vol. 14 No. 1 additional stresses to their lives (17,18). Children with hearing loss showed lower scores for problem solving, higher scores for coping strategies, including anger-related emotion regulation, seeking social support (girls) and using media (boys) (17).
Psychologists have always been interested in the risk and/or supportive factors that impact individual's well-being. Studies (19) on coping strategies in adolescents are focused on how this group cope with negative emotions (worry, sadness, anger, helplessness and pessimism). Investigating how adolescents cope with their emotions is of great importance, however coping strategies may be more important than the emotions themselves to affect well-being (20). In children with hearing loss, everyday stressors (such as being communicated with others) are experienced as more stressful than normal hearing pupils. They have problem in using some of coping strategies (17), which can result in well-being impairments.
Based on relevant studies, using coping strategies has a significant relationship with well-being (21).

Participants
The study population consisted of 122 students with hearing loss. They were recruited from mainstreaming schools (studying in the 6 th to 9 th

2) The EPOCH Measure of Adolescent Well-
Being. This is a 20-item scale based on the well-being theory and assesses 5 positive psychological characteristics of well-being, including engagement, perseverance, optimism, connectedness and happiness (9). A 5-point Likert scale ranged from never (1) to always (5) was used to answer the items. The total score for each positive characteristic is consisted of sum of scores of related items. Higher scores are representative of higher levels of well-being. In present study, the Cronbach's alpha coefficient of the EPOCH for students with hearing loss was obtained 0.749.
3) The Ways of Coping Questionnaire: This is a 66item questionnaire assessing thoughts and behaviors used by people to deal with stress (3). The items are grouped in 8 ways/strategies of coping, including confrontive coping (6 items), distancing (6 items), self-controlling (7 items), seeking social support (6 items), accepting responsibilities (4 items), escapeavoidance (8 items), painful problem solving (6 item) and positive reappraisal (7 items). The participants are asked to report the extent, to which they use each strategy and the questions are scored on a 4-item Likert scale with scores ranging from 0 to 3 as follows: 0 (not used), 1 (used somewhat), 2 (used quite a bit) and 3 (used a great deal). In present study, the Cronbach's alpha coefficient for students with hearing loss was found 0.905. SPSS version 21 was used for statistical analysis.
The means and standard deviations and Spearman correlation coefficients were calculated for data analysis. P<0.05 was considered as statistically significant.

Results
The study population consisted of 122 adolescent students with hearing loss. The well-being of the adolescent students with hearing loss who were studying in the regular schools was measured by EPOCH Measure. The results are shown in Table 1. Based on the EPOCH, the scores for each positive psychological characteristic are ranged from 5 to 20.
As shown in Table 1, the mean scores for the five positive psychological characteristics ranged from 11.04 for happiness to 12.33 for connectedness in a 5-20 grading scale.
The mean scores of coping strategies in adolescents with hearing loss in the mainstreaming schools are shown in Table 2.
Iran J Child Neurol. winter 2020 Vol. 14 No. 1  As it can be seen in Table 3

Discussion
This study was done to assess the coping capacity and well-being of adolescents with hearing loss and also to determine whether different coping strategies are correlated with EPOCH.
Regarding the first objective, the results of this study revealed that in students with hearing loss, the mean scores for using different coping strategies ranged from 1.36 in using problem solving to 1.44 in seeking support strategies. Eschenbech et al. study (17) indicated that children with hearing loss scored higher than hearing children in seeking social support. They stated that children with For the second objective, the results of this study showed significant correlations between coping strategies and EPOCH. Although the relationship between overall well-being and using coping strategies has been studied, the researchers have used different measurement tools. Ryff (27) and Keyes (28) measured subjective well-being and their results showed that the higher level of well-being was associated with higher use of coping strategies in youth (29). The findings of this study Students with hearing loss the strong associations between optimism and coping strategies (seeking social support and positive reappraisal more than others), Iran J Child Neurol. winter 2020 Vol. 14 No. 1 connectedness and coping strategies (seeking social support and problem solving more than others), happiness and coping strategies (problem solving, seeking social support more than others).
Higher levels of social connectedness and social support are associated with better physical and mental health outcomes (30). Social connectedness and social support act as the protective factors against stress, by which individuals under stressful situation can use seeking social support as a coping strategy to face the stress (31). Normal hearing individuals with high social support might be more optimistic and can better cope with stressful situations, which can lead to more positive health outcomes (32). Studies on happiness indicated that coping strategies influence happiness. Being in a group is associated with happiness for adolescents (33,34), where social support and coping have a proper association with well-being in them (35). Our finding also revealed that two positive characteristics of wellbeing, including engagement and perseverance were more strongly associated with problem solving coping strategy than other coping strategies in adolescent with hearing loss.
Problem solving is engaging in a task, for which there is no known solution and the students must persist on the task to be able to solve the problem.

Conflicts of Interest
None declared.